This is part two of a series of National Audio Teleconferences sponsored by the User Liaison Program, Agency for Healthcare Research and Quality, conducted on May 24, 2000.
CINDY DIBIASI: Good afternoon and welcome. My name is Cindy DiBiasi and I'll be your moderator for today's session.
This is a second of the ULP teleconference series on medical errors. And today's call will address the issue of how States can improve patient safety and reduce medical errors.
Today we're going to discuss how States can use their purchasing and regulatory role to educate the public and work with stakeholders to improve patient safety. Several States have interesting reporting systems and we'll hear about two of them today.
We have a panel of three experts with us in the studio today. Fred Hiegel is the Director of the Bureau of Hospital and Primary Care Services in New York. Welcome, Fred.
Janet O'Shulsky is the Director of the Quality Improvement and Eligibility Services Bureau at the Michigan Department of Health. Janet?
And Nancy Ridley is the Assistant Commissioner of Health Quality Management at Massachusetts Department of Health. Nancy?
Before we begin our discussion, I have a few housekeeping items to take care of. Later in the call, our final panel of experts will be taking your questions.
Now, there are three ways you can communicate your questions to us. You may ask your question over the air by pressing 1 on your phone pad. This will put you in the queue. If your question has been answered or you want to drop out of the line, press the pound sign.
You may also fax us your questions. The number is 301-594-0380. Or you may E-mail us your question at info@ahrq.gov. If you prefer not to use your name, that's fine. But we would like to know from what department or organization you're calling. So please indicate that in your E-mail or fax.
We will have tapes of this teleconference available for purchase after the series is completed, and I'll give you further details about that at the end of the show.
But now I think we're ready to turn to the important matter of States, and their world in addressing medical errors. And, Fred, I'd like to start with you.
New York has developed a mandatory reporting system. When did that system begin and why was it started?
FRED HIEGEL, DIRECTOR OF THE BUREAU OF HOSPITAL AND PRIMARY CARE SERVICES, NEW YORK: Well, Cindy, initially it began in October 1985, as a regulatory effort. It was in regulation; however, the following year during the medical malpractice reform era, the industry came to government to try and seek some reform from high malpractice premiums. And, to some extent, some reform was provided in the form of some relief through excess malpractice liability coverage for hospitals. But, together with that, the incident reporting regulations were then put in the statute and became mandatory together with mandates regarding quality assurance, credentialing. And right now, we are reeling in the third iteration of that program in New York. And it's called NYPORTS, the New York Patient Occurrence Reporting and Tracking System. And, as I said, the third version of incident reporting that we've achieved so far.
DIBIASI: And who submits those reports and what do they include?
HIEGEL: Well, the reports—the statutes primarily cover hospitals—The Q Care hospitals. To some extent, it also covers freestanding clinics. You know, ambulatory surgery centers, dialysis centers. It does not include long-term care facilities or private medical practices. The focus is at Q Care hospitals.
Facilities report in two forms. NYPORTS is an adverse event reporting system. It's not solely a medical error reporting system. So if there's an adverse event that occurs, the facilities are required to report to the department.
There are two forms, as I said. One is a short form report which, basically, captures data regarding the occurrence of an event. And in addition to that, there's a long form reporting which involves an investigative phase. And, frankly, we're moving on June 1st to a root cause analysis format for that. And what that involves is an internal investigation by hospitals with respect to the adverse event. And the determination, or the distinction, between long form and short form is the actual outcome involving the patient. Investigative reports are required if there's a significant impact on the patient.
To give you an idea: there are 9 overall reporting categories; 51 types of adverse events; and 13 of those types of adverse events require the root cause analysis, the investigative reports, to be submitted to the department.
DIBIASI: What is done with that data?
HIEGEL: Basically, the department—now NYPORTS has been around since April 1st, 1998. So, at this point, we're developing a database, and we're doing two things initially.
The first is that the database is something that's accessible by facilities that report into it. So they can use it for comparative analysis to support and, hopefully, assist them in their own internal quality improvement activities.
In addition to that, to date the department has some initial analysis. And what we try to do through a newsletter that we share with facilities is provide feedback on best practices, system development issues. Those sorts of things. We do have future plans which, hopefully, we'll get to later on that I can describe in more detail, as well.
DIBIASI: If States are just starting a mandatory reporting system and they come to New York for advice, what could they learn from your experience?
HIEGEL: Well, you know, we do have about 15 years' worth of experience. And, to some extent, have learned by mistakes, as you would with any system of this nature. Certainly, we're more than willing to openly share anything that we've got in our system so that facilities don't have—States don't necessarily have to go through the same exercise.
With this third iteration, basically how we developed it—we developed it collaboratively with the industry, with consumer representatives, with government, with industry associations to try and develop a system that could be as win/win as possible. So that everybody has something to gain from it. Obviously, there's a mandatory requirement for reporting. But in addition, we're trying to give something back to the facilities and try and encourage them to report properly and to use it. So I think that—you know, that approach has worked far better than the previous two.
In addition, what we did is—we really pretty exhaustibly field-tested it prior to putting it into use. And how we did that was we did it in small groups of facilities. And we expanded on that, and gave them the opportunity to try it, to provide input for further development and refinement of the system.
DIBIASI: You know, if you were to choose the three or four elements most critical to the success of the New York system, what would they be?
HIEGEL: OK. Well, one thing that is in our statute—which I think is really critical to facility reporting—is there's a statutory protection from public disclosure. So the reports that facilities provide to the department are protected by law. And we've got a flawless track record with respect to protecting that information.
In addition, something that we've found over these years is that—a critical element is clear definitions of the types of events that need to be reported. We have what we call an includes/excludes concept which—you know, basically, in medicine there's a range. You know, it's not all necessarily all black and white. There's a lot of gray. But through our definitions, we try and—based on the level of significance of the event and the quality improvement value of having the data have very careful and clear definitions. And those are continually refined with input from the industry.
We've also tried to make this system of reporting easy for facilities, both from the standpoint of types of information they have to provide and the method of providing it. What we've developed is—what we feel, at least—is a state-of-the-art Internet-based electronic reporting system so everything is done through a PC located at the facility. It's all done electronically and the system has built-in security. And that also was extensively field-tested when we were developing the system. And something—as I briefly mentioned earlier that I think is an important aspect is the development of databases that facilities can then access themselves.
Historically, we have collected a lot of data. But, frankly, it was very difficult to really analyze that data and feed information back. And now the system has developed so that the people who have input data into the system can access the database to compare their experience either to a peer group, or to a regional group of facilities, or on a State-wide basis. And we really want that to be—oh, a building block or a foundation for quality improvement within facilities. And we want to try and help them with that in developing this database. And giving them direct access to it has brought with it substantial success.
DIBIASI: Give me an example of how that might work if an institution is trying to access information. What type of information would they access from the database and how would they use it?
HIEGEL: OK. For example, if a facility is—analyzes it's phone data and finds that it has a fair number of DVT (INAUDIBLE) occurring in a station population, but it wants to see how it compares to the rest of the State, you know. Is this really a high number? Or is this really within the State average?
They can then take that number that they—and this is all weighted, so it's not just raw numbers, and they can compare themselves to a peer group of facilities that purportedly are like it like that. Not without knowing their names, but, you know, just a peer group, and compare itself in that way.
It can compare itself with respect to what's being reported throughout the region, as well as reported throughout the State and see just how it fits. You know, is it really standing out with respect its volume? Is it something that it needs to focus its efforts on? Or is it really within the norm and overall quality improvement sort of approach as compared to something that's stands out dramatically?
DIBIASI: A way for them to signal whether they have a real problem, or whether this is an issue, or whether they need improvement in this area.
HIEGEL: Yes. In many facilities they're using it just for that which it's designed for.
DIBIASI: It seems like it's a fairly refined system you have in New York. You talk about these several reiterations in development. Considering that there is a certain level of refinement in the system, what are some of the future plans for it?
HIEGEL: Well, you know, we recognize it's not perfect. And, certainly, in the future, we intend to continue to refine and improve the system. That's been—you know, it's been an ongoing development stage.
Really, from the standpoint of initial concept through implementation was about an almost 3 year period, and now it's been in place for roughly 2 years. So, it's been a lengthy period. We intend to continue that refinement and improvement of the system for one thing. For example, you know, continually clarify definitions. To try and make sure that we have consistent and complete reporting.
But since the system has become relatively mature, there's a large volume of valuable data included in the system. And, at this point, what we intend to do is—and we're going to do it really through contracting out with an expert to do a more in-depth analysis of the data that are in the system to see what's really in there, to see what lessons can be learned. To see actually what information would be useful and helpful to share with the public. We haven't really done that so far. The newsletters that we issue have been fed back to facilities. But in order to conduct the data analysis, the initial phase will include a validation for the data that's in the system. And we intend to compare it—well, at least, have our consultant compare it to sparks data, to e-code. The complication codes that are included there.
We intend to use our utilization review agent in the review of Medicaid charges to determine if there were adverse events that should have been reported in the system and, indeed, were they reported?
We also—through our ongoing surveillance activities, as an element of that—have done our own sample validations through the investigation of complaints. Many times the basis of a complaint is an adverse event or a perceived one. And it—sometimes just in the course of review of the care of an individual patient, we'll identify an adverse event. And then we try and do a check and balance to determine if that, indeed, was reported through the system.
So what we're trying to do with the analysis is, in addition to having useful information that we can then share with facilities and the public, is also to validate the system and to insure the best we can that there's complete and consistent reporting.
As I mentioned, also, we do, at our level, conduct some level of analysis to try and do really two things. Identify best practices sorts of things that we can feed back to the facility so they can use that to improve their own internal activities, as well as to give updates on the system. And we intend to continue those newsletters, as well.
DIBIASI: OK. Well, we'll be back in a little bit.
HIEGEL: OK.
DIBIASI: To discuss in more detail about this. But, Janet, you were part of ULP's March 2000, workshop where they talked about medical errors. And that—the fact that States have multiple roles in protecting patient safety. Let's review what they are.
JANET O' SHULSKY, DIRECTOR OF QUALITY IMPROVEMENT AND ELIGIBILITY SERVICES BUREAU, MICHIGAN DEPARTMENT OF HEALTH: OK. Well, first there's the role of the purchaser, which I represent here.
States buy a lot of healthcare. They buy it for their employees and families, retirees. They buy healthcare for Medicaid beneficiaries, for children who are part of their State Title 21, children's health insurance programs. They also buy care for prisoners in their correction system. Anyone who is part of their program for the uninsured, et cetera, so that's one big role that States have.
They also have a role as regulator. They regulate different providers in the healthcare system, et cetera. They may also be providing healthcare directly either in facilities settings by the State hospitals, children's facilities, things of that nature, or in community based settings. There are States who actually provide care directly. And then, finally, States have a role as kind of convener and leader in the healthcare arena whether that's through their public health role, or other—just State governmental roles.
They have—they can bring people together to discuss issues, and to come to consensus on proposed solutions, or to develop guidelines, et cetera. So there are about four roles that the States have.
DIBIASI: And States have a fair amount of power in terms of their role as purchasers. How could these purchasing strategies be used to improve patient safety?
O' SHULSKY: Well, I think first off, they can be used by just focusing attention on the subject as a—as you said, States do have leverage as purchasers. And they can use that to engage the healthcare community—whether it's hospitals, physicians, nursing homes, health plans—in conversations about what is the state of patient safety in that particular State of the country. And where do we need to go to begin the conversation? And then they can use the money that they use to buy healthcare to provide incentives so that people actually start to improve patient safety.
DIBIASI: Now, there's something called the LeapFrog Group, and I know they've actively developed a program in this area. Could you tell us who they are? And what lessons their initiative has for States ?
O' SHULSKY: Certainly. The LeapFrog Group is a—started as a group of large, private purchasers. It was founded by General Motors Corporation, GTE, General Electric, the Pacific Business Group on Health, The Buyers Healthcare Action Group out of Minneapolis. And then, also, the Federal Office of Personnel Management was an original founder of the group, as well.
It's now been expanded to include other large purchasers of healthcare, as well. And they came together, in essence, to try and help the healthcare system make great leaps in terms of improving patient safety.
DIBIASI: That's the name.
O' SHULSKY: That's the name—in improving patient safety.
DIBIASI: And how did they decide on which strategies they were going to pursue?
O' SHULSKY: Well, there—certainly they looked at several different strategies. And they decided it had to be—the strategies they choose had to be something that made sense, and that it made sense to more than them—themselves as sophisticated purchasers.
Is it intuitively obvious to non-medical people that this would make sense to do? Is it easy to understand? I—kind of what one health plan medical director talked to me as the mom test. You know, can I explain it to my mother? Can I explain it to my grandmother? Also, what difference will it make? Is this effort something that will give us significant improvement in patient safety? Or it something that'll only give us moderate improvement? And they certainly were going to for the leap. The areas that they felt would give significant improvement. And then, also, the very obvious political question, sort of, who would object? Who's out there? What kind of controversy surrounds this area? What kind of evidence is there that this does work? Things of that nature.
DIBIASI: Now, can States join the LeapFrog program?
O' SHULSKY: I believe States can join the LeapFrog program. I—not being a member of it myself, but in sort of speaking for Bruce Bradley, today of General Motors, I'm sure they're interested in having States join it. And if States are interested, I can certainly give them the contact information for that.
DIBIASI: Now, how does being a public purchaser differ from a private purchaser when they're trying to address this issue?
O' SHULSKY: Well, I think it—States differ in three basic ways.
First, often we don't act entirely on our own. Many of the programs that we operate outside of our coverage for State employees and retirees, are Federal and State programs. For example, Medicaid, or the Children's Health Insurance program. And, so, we're operating with both Federal guidelines and regulation, as well as our own State guidance. So we have a—we have a shared responsibility as it were. Also, we do have other roles and I think that's different.
Private purchasers really focus on the purchasing. Because we also have a role as regulator and convener, and provider, we can sometimes experience role confusion. And sometimes, as a purchaser, we'll almost try to act more like a regulator. And that may not be quite as effective as using our purchasing strategies in a true sense. And then, finally, we—everything we do is in the public's light. You know, we're—we do everything in full view of consumers, the legislature, et cetera. And that just tends to give your conversations a different tone and a different timetable basically.
DIBIASI: OK. Nancy, we're going to come back—or Janet—I'm sorry—I'm going to come back to you in a little bit. But first I want to go to Nancy Ridley. And just a reminder, the Assistant Commissioner of Health Quality Management of the Massachusetts Department of Health. That's a mouthful.
And, Nancy, I know that Massachusetts has formed a coalition for the prevention of medical errors. Why was that created?
NANCY RIDLEY, ASSISTANT COMMISSIONER OF HEALTH QUALITY MANAGEMENT, MASSACHUSETTS DEPARTMENT OF HEALTH: Well, it's really quite simple.
In Massachusetts we had probably one of the most significant and memorable incidents that occurred with a serious chemotherapy overdose at Dana Farber Cancer Institute that involved a much-beloved Boston Globe columnist—health columnist that all of us knew. And she and another woman—she died, unfortunately. And another woman was seriously injured from this same protocol event—adverse event. And, as a result of that which occurred—actually at the end of '94—it wasn't discovered until early 1995. The intense media attention and public awareness that those events that were followed very—in a short period of time within that next year by two or three other well-publicized serious incidents in Massachusetts, really catalyzed an effort on the part of Massachusetts to want to do something to address the problem which we were beginning to recognize was much bigger than an isolated type of problem.
So the department, and actually the regional vice president from the Joint Commission—we met and shortly after Annenburg—the first Annenburg conference on patient safety to float the idea of bringing together a couple of private partnerships as a—in the form of a coalition to prevent medical errors.
DIBIASI: Now, who was involved in the coalition?
RIDLEY: Well, on day one it was the Joint Commission—regional Joint Commission Commissioner and the Department of Public Health. Shortly, when we had our first organizing meeting, it included the Massachusetts Hospital Association and the Medical Society in terms of our exploratory work group. When we actually had our first meeting, we probably had about a dozen organizations and agencies that were at the table initially. By the time we went public, which took about 18 months, we had about 25 organization members to the coalition.
DIBIASI: And what are the coalition's goals? And what's the mission?
RIDLEY ; Well, it has—it's really—it stems, I think, a lot from what we in the Department of Public Health look at being a real strong prevention mission and goal.
Our initial short-term goals were to identify and disseminate best practices. And we began with medication errors, obviously, because that was our primary sentinel event at the time.
We've since expanded on a short-term basis to four or five other categories of best practices which we're working on. Short term: in addition to developing and disseminating the best practices, we really have focused on a number of education and training initiatives amongst the various member organizations and for the healthcare industry as a whole. Long-Term: we have goals which we've begun working on that are intended to take a critical look at regulatory duplication because we have a complex regulatory schematic in Massachusetts. And we want to look at duplication and simplification. And, also, see if there are any gaps in what we're currently doing. And our long-term goal is also to change the culture of fear to one of safety.
DIBIASI: How do you staff it?
RIDLEY: OK. Right now, the—up until this point, the funding and staffing for the coalition have totally been from the member organizations. Most of the financial support in dedicated staffing has come from the Massachusetts Hospital Association and the Department of Public Health.
The department has funded a half-time position for the last year and a half. The department has just committed to funding an executive director position, or $100,000 worth of an executive director position. So we'll be having our first really dedicated executed level staffing that will be—we're in the process actually—we have a job description—we've begun recruiting for an executive director.
At the coalition itself, we'll be housed at our State hospital association. It won't be under the hospital association but it'll be housed in their building. And there will be the staff positions I'm already funding plus some in kind staffing that comes from some of the organizations. So—but we will have our own—we're actually establishing, also, a corporate structure of 501C3 or 5013C6 type of status for the organization so that we will be able to attract Federal and private grant funding as well.
DIBIASI: What were some of the biggest challenges and problems the coalition confronted when it got started?
RIDLEY: Well—that's why one of the reasons it took us 18 months from the date we started meeting until July of '98 when we actually formally kicked it off is that we were addressing some of the real touch issues that go along with unnatural alliances.
When you get regulators and the private sector in the same room—and we had Boards of Registration; we had the Department of Public Health; we had—HCFA (Health Care Financing Administration); we had the Joint Commission in the same room with the individuals who we were regulating. And it took us a year and a half to overcome some of the fear and some of the mistrust that had developed over the years. Because I think in some cases Massachusetts systems—we have a pretty open system where a lot of our information does—is available to the public and to the media. So there was a lot of fear and trust that had to be built initially. And those were some of our biggest hurdles.
DIBIASI: And what have you accomplished?
RIDLEY: Well, we've come out with a set of best practice—well, short-term and long-term best practice recommendations in medication errors. There are about 14 best practices that we've come out with. Some are short term, some are Long-Term.
We came out with those a little over a year ago, and we're actually in the process of evaluating the degree to which they have been implemented in all of our State facilities—all of our hospitals at this point.
We took some of these best practices and didn't just stop with hospitals. But we've turned some of them into tools for other types of areas like long-term care facilities where the same types of errors are occurring as in current hospitals. And we've tailored some of these tools to other types of settings.
DIBIASI: Which will become more and more important as more and more healthcare is delivered outside.
RIDLEY: Exactly. That was exactly—our focus is not just on the Q Care sector. It's also on ambulatory, as well as long-term care, and really trying to tailor the best practices.
I think a lot has been—an awful lot—maybe too much focus on—just on the hospital sector. Not that it's not important. But we do have—we have to make these same best practices available and bring them to the other forms of healthcare delivery.
DIBIASI: OK. We'll be back in just a few seconds and talk to you more about this. And in a moment, we're going to open the phone lines for questions.
Recall that you can send your question over the air, and you can also send us your question by fax at 301-594-0380. That is the fax number. You can also E-mail your question at info@ahrq.gov. And if you want to ask your question over the air, just press the number 1 on your phone pad. This will put you in on the queue. And if your question has been answered or you need to drop out of the queue, you press the pound sign.
Before going to the questions, I want to say a few words about AHRQ and the User Liaison Program.
The mission of AHRQ is to develop and disseminate research-based information that will help clinicians and other healthcare stakeholders make decisions to improve healthcare quality and promote efficiency in the way that healthcare is delivered.
The User Liaison Program serves as a bridge between researchers and State and local policymakers. We not only take information—research information to policymakers so they're better informed. We also take the policymakers' questions back to researchers so they're aware of the priorities.
Hundreds of State and local officials participate in ULP workshops every year. And as a new addition to the ULP portfolio of products, we hope that today's call, and the other calls in this audio teleconference series, will provide a forum for discussion between our audience of policy-makers and researchers like those who are joining me for our discussion today.
We'd appreciate any feedback you have on these teleconferences. Please E-mail your comments to the AHRQ's User Liaison Program at info@ahrq.gov.
Now to your questions. This one was faxed to us.
Janet, you described the LeapFrog initiative. Can you give us a specific example of their activity on a project maybe that they implemented to improved safety ?
O' SHULSKY: OK. They're—they're actually just getting started and they're focusing in three areas. But one in particular is the whole notion of evidence-based hospital referrals. Having certain procedures that have been demonstrated in the literature to be done better when done by people and in facilities who do a lot of them.
They are looking to promote the use of those types of facilities for their employees and the people that they cover. So, for example, whether it's coronary artery bypass surgery, or repair of aortic aneurysms or esophageal cancer surgery. They are, basically, looking to encourage their health plans, and they, themselves, to directly contract with facilities who meet the volume requirements and, also, have outcomes that show positive outcomes that are higher than the regional norms. And they would also be—along with this, they would be providing information to their employees, dependents, et cetera, about why it's important; providing economic incentives to those individuals to use these facilities, as well as the financial incentives to the facilities for performing their procedures.
DIBIASI: We have Sandra on the air from Colorado.
ED: Actually, you have Ed on the air from Colorado in the same office.
DIBIASI: OK. You don't sound like Sandra.
ED: I'm curious about the—still putting down some of the definition of medical error. Last time, Dr. Leape had said a medical error is something where you do it, and almost immediately you go: "Uh-oh, I shouldn't have done that."
On the other hand, there are situations in which it becomes apparent in retrospect that: Well, maybe that wasn't such a good thing to have done. And you've been talking about best practices guidelines. And sometimes things may not be the best practice, but maybe it may be debatable. So I'm curious what kind of concept of medical error you're dealing with here.
RIDLEY: I—this is Nancy Ridley.
I think that one of the problems has been the lack of uniformity in definitions. In fact, if you read the summary of—the 50 State summary that was just put together about reporting or dealing with medical errors, I don't think there were any States that actually used the term medical error.
It's usually a serious incident, adverse event. And I can tell you just from our standpoint that the incident that occurred with the chemotherapy overdose—this was not actually detected for four months. It took four months to realize what actually had happened that—that there had been an incident that resulted in a four-fold overdose.
So, oftentimes, I think the term medical error is maybe something that—at least, we on the State level are not using to define what it is that we're going to look at and explore further.
HIEGEL: And this is Fred. I agree with Nancy.
Actually, as I mentioned, our system is an adverse event reporting system. It's not focused solely on medical errors. So there does not have to be an attribution, per se. But it's really an unexpected adverse occurrence that's involved the patient. And that's what—you know, we expect to be reported. And we capture that information in our database.
ED: Am I still on the line?
DIBIASI: Yes, you are.
ED: So sometimes in the case of the overdose—the chemo. If it had been called to someone's attention five minutes before it happened, they would have known to say: "Oh my god, I better not do that."
On the other hand, sometimes decisions are made where you get the autopsy back and you say: "Ah-ha, so they had this rather than that." And it wasn't—even five minutes before the action was taken—apparent that it was going to be a bad decision or an error. And I'm just kind of trying to sort out those two kinds of situations.
RIDLEY: I do—I do think that oftentimes doing a root cause analysis is what it takes. And, oftentimes, those take some period of time after an event occurs.
In the case of the chemotherapy overdose, it actually was a data coding clerk four months later who was sending information into the clinical trial, NIH-type (National Institutes of Health), NCI (National Cancer Institute) sponsored, who actually determined what the—what the error was that occurred.
So, oftentimes, it's going to take significant research and evaluation, and really good in-depth evaluation of a root cause, in order to determine what was the cause of an adverse outcome.
HIEGEL: And I agree with Nancy on that point. And that's why effective next week, actually, we are shifting our—you know, the long form that I mentioned, the investigative format, to the root cause analysis format because, frankly, we view it as a superior quality improvement mechanism.
DIBIASI: Next—John, I believe is from Indiana? Hello?
JOHN: Hello. I'm here.
DIBIASI: Oh, hi.
JOHN: I have two questions. One for Nancy and one for Fred.
DIBIASI: OK.
JOHN: Nancy, are your short and long-term best practices available for other States to use?
RIDLEY: Yes, they are.
On the medication error—in the medication best practices, they are actually on the—you can get them off of the Massachusetts Hospital Association's Web site which is www.mhalink.org. And you can just follow the link to—if you go mhalink.org/mc—Massachusetts Coalition For The Prevention Of Medical Errors—mcpme.
JOHN: OK. Thank you.
RIDLEY: You'll get—you'll come to the coalition's temporary home and you'll find the medication's best practices there.
JOHN: All right. Thank you. And the same question for Fred.
You talked about short and long-term—short and long forms that you were using and categories and best practices. All right. The root cause and the advance, are they available the same?
HIEGEL: Well, actually, John, you know, our forms aren't yet posted on the Web site. Although we do plan on sharing that information with AHRQ for posting on theirs. But as far as—you know, the format will be there and we'll openly share that. But with respect to individual reports by hospitals and individual root cause analyzes, we are prohibited by law from sharing that information.
So, certainly the format's available, as well as our includes/excludes, our definition list. We're going to make that available to AHRQ so they can post that information, and it'll be available to everybody, hopefully, from their Web site.
JOHN: OK.
HIEGEL: That helpful?
JOHN: And one other item on your system. Is it punitive in any way?
You talked about the—it being confidential and protecting it from public exposure and clear definition and easy reporting. But I'm concerned if there's anything punitive for the people who report?
HIEGEL: Well, that's a good question and, indeed, we've tried to make it a non-punitive system for reporting. It is punitive if you get caught not reporting. That's a given as a mandatory State system. And there's also another punitive aspect in the long form, the investigative report.
If a facility makes a determination that a practitioner, an involved physician, was the basis of the adverse event, or some human error, or the basis of the standard of care not being met, and reports that to us, we then refer that to the office of Professional Medical Conduct, our Board of Medicine, for whatever action they may take. But that could result in punitive action, as well.
JOHN: OK. Thank you.
DIBIASI: What is the punishment for not reporting?
HIEGEL: Well, the punishment—actually, that's interesting you ask that.
Our commissioner just sent a letter to facilities in February. Because we became aware of three sets of circumstances that clearly should have been reported that had significant harm. And, basically, in her letter, and she's said this publicly a number of times that I've been with her, if you get caught not reporting: First, she's going to embarrass them by putting their name in the paper; second, fine them in accordance with what the statute allows; and third, require they get a consultant in to fix their quality assurance system.
UNIDENTIFIED PARTICIPANT: That's incentive.
DIBIASI: Our next call is from Wisconsin, Richard from the Division of Health. Hello?
GARY OLMENISS: Hi, this is Gary Olmeniss.
DIBIASI: Hi.
OLMENISS: Wisconsin.
DIBIASI: Hello.
OLMENISS: I'm a nurse consultant in the managed healthcare programs, and I work primarily in the quality improvement areas of our Medicaid managed care contracts.
We've heard from Mr. Hiegel on the reporting—mandatory reporting approach and from Nancy Ridley on education to best practices. But what we really haven't heard on—about is the delivery part.
In other words, who's measuring the results and assessing whether or not all this reporting and education is bearing any results?
RIDLEY: Go ahead and take a crack at that.
HIEGEL: You know, maybe I can start.
You know, that's what we're intending to do somewhat with our analysis—our analysis piece. And, you know, we've developed somewhat of a significant database, and we're hopeful to be able to assess that over time. And, in fact, in the Institute of Medicine's report, they challenged the States to reduce medical errors by 50 percent over the next 5 years.
My commissioner and Dr. Nobella have openly accepted that challenge. And, frankly, we want to be the best—the first State in the nation to achieve that level of reduction. Certainly, in order to do that, you need to assure that you have complete data in the first place so that you can measure any change. And, hopefully, through the analysis of the data, the feedback in sharing of best practices and quality improvement strategies, we'll be able to, you know, reduce the number of reports we get; reduce the number of events that occur. And, hopefully, over five years, which, frankly, is a significant challenge, achieve the challenge that's been set forth by the Institute of Medicine. But we're really just starting on that phase now.
RIDLEY: I—this is Nancy. I totally agree with Fred.
I think until the IOM (Institute of Medicine) report came out, most States, basically, weren't—it wasn't high on the radar screen in terms of what were we doing collectively between the public and the private sector to prevent medical errors. And I think the IOM report and initiative, such as what Fred's doing and what Janet's doing, and what Massachusetts is doing. I think that, as we develop the different regulatory, investigative, educational, and training initiatives, we have to make sure that we build an assessment mechanism until we find what works and what doesn't.
Our medication initiatives, our best practices, we're in the process of an in-depth analysis one year down the road of what difference it has made in all of our institutions, and what practices have been incorporated, and what difference has it made. So building an evaluation is critical.
UNIDENTIFIED PARTICIPANT: And, in the meantime, anecdotally, what have you seen, Nancy, in terms of a difference?
RIDLEY: Well, one of—some of the things we've seen when we identified—when we broke down some of the common factors and some of the errors that we were seeing, and I'll just bring up two examples. One was wrong root of administration of medications.
When we were—wrong root of administration of medication and calculation errors. Milligram versus—milligram versus milliliter, and the difficulties that many personnel have in distinguishing between those two concepts of amounts of a drug to be given.
Once we develop some tools—some quick tools for use in the facilities, we found that there was a much higher level of recognition of—an avoidance of a problem. We also came up with a system for initial competency testing for all new staff who are going to be administering medications in long-term care facilities. Because a lot of the problems that were occurring were occurring in long-term care where the matter that the individual was a registered nurse. They needed to have some type of initial competency assessment in order to make sure that they actually did know how, on their own, to be administering the medications.
DIBIASI: John, from the Texas Department of Health. Hello?
JOHN ADAMS, TEXAS DEPARTMENT OF HEALTH: Thank you. Greetings from Texas. I have questions for Fred and Nancy.
First of all, Nancy, I didn't hear you mention a reporting piece. Do you have that as part of your program?
RIDLEY: Oh, absolutely. We have mandatory reporting. Actually we have two reporting systems in Massachusetts.
Ours goes back to the—at least the early 1980s in the Department of Public Health where it's all—all hospitals, nursing homes, clinics, ambulatory facilities are required to report serious incidents. And there's a long list of the definitions of what constitutes mandatory reporting as basically anything that requires significant additional diagnostic or therapeutic interventions. And there's a long list of examples that you can find either on our Web site, or, I think, they were putting up slides from some of the presentation that we're given today. So, yes, we do have mandatory reporting in the department and to the Board of Medicine, as well.
ADAMS: OK. Thank you.
Fred, I was curious as to the volume of reports that you get. And what does it cost—got any idea in the cost to set up your system? Or, if not, just a cost to maintain that system?
HIEGEL: The volume of reports—that's an easier one for me to answer, frankly.
We're up to roughly 20,000 reports of adverse events per year. Of that 20,000, 19,000 are the short-form variety where we just gather data. And roughly, 1,000 are those that require investigation on the part of the hospital and they have to provide us with their investigative report.
Interestingly, with respect to costs, we kind of did this, believe it or not, in sort of a low budget approach in that from the standpoint of personnel was quote "existing resources" that put this together. And what we did was we, basically, put together a group of people from outside the department effectively as volunteers. Which included people who are, you know, medical directors of facility; the surgeon; anesthesiologist; representatives of the State societies; a consumer representative. And, basically, through their input, and, you know, ideas, we've developed a system. And, frankly, what we've basically done for them is feed them lunch a couple of times a year, and that group has been getting together for five years now.
With the money that was spent was on a development of the Internet-based electronic reporting system. And that was, basically, funded through grant funds from the department. And, so far, we—and interestingly, we did bid. And we did find a company that was a relatively small company that actually was looking to grow and become—you know, have New York State government as a client. So they bid relatively low, basically half of what any other company did. And the first grant to develop the system was $160,000, which you probably couldn't duplicate it. Certainly not with the development now. And we just paid them an additional $50,000 for refinement of this system—upgrade to the system to involve the root cause analysis, the improved definitions and things like that. Hopefully, we'll be able to continue some level of grant funding to support the system.
Built into the first year's contract there was, basically, I guess, an annual maintenance fee, or something like that, which was roughly $20,000, as well. But other than that, with respect to actually managing the system and running the day-to-day activities, we do that through the bureau and several field offices that are overseen by the bureau with the existing personnel resources that we have on hand.
ADAMS: Thank you.
DIBIASI: Fred, if a State wanted to take the New York model, how—now that you've made all the mistakes and gone the long way—how difficult would it be? Would it—how costly would it be? And is it easily transferable? Do you see your model working in all the States? As we were saying before, there are really only a handful of States that are doing it on their own now.
HIEGEL; Well, you know, I think from a standpoint of the generic adverse events, the same type of events are occurring everywhere. And we would be happy to share, you know, the entire NYPORTS package from the standpoint of the process; the forms; the definitions; all of that, with anybody for free.
To develop the electronic reporting system, they would have to either seek out our consultant, or one of their own, to do that because that's not something that we could readily share. It would have to be adopted for each State. And, certainly, they've probably changed their name from NYPORTS to whatever State it was, but we'd be happy to openly share that. We have done that.
We have actually had people as far—we've had folks from Great Britain come and visit and see a demonstration of the system; take information back; assisting a neighboring State. We went down to New Jersey and made a presentation there just last month.
There's been a wide—you know, a wide level of interest and we just openly shared the entire package. We'd be happy to do that with anybody that would like it.
DIBIASI: Great. From the Washington Department of Health—Donald? Are you there?
DONALD WILLIAMS, WASHINGTON DEPARTMENT OF HEALTH: Yeah, this is Don Williams.
DIBIASI: Hi.
WILLIAMS: I'm wondering what kind of behavior change any of the States have seen as a result of these—these programs? Because it seems to me that's the area that's going to have to occur if we're going to make changes in this system.
RIDLEY: Well—this is Nancy.
We have seen a lot more openness. I think, initially, when we started our coalition, there was a lot of fear to even talk amongst institutions between—between themselves. Or to admit that they had problems, or that problems were occurring.
We have seen a much greater openness, not just with them talking to us as the typical fear of regulators. But also talking amongst themselves. And I think having established a number of forums, that they feel safe and that they can come together and share experiences, has been exceptionally positive.
People are disclosing things and talking because they realize they're not going to be blamed or criticized for what's happening because it's happening to everyone. I think there was a loathing to do that until—until the last year or so.
HIEGEL: And this is Fred.
I—you know, I agree, again, with Nancy that we've seen a lot more openness. We've probably seen it on a little smaller scale, though. And the reason I said it is: in addition to the statewide steering committee that's developed this process, we set up what we call regional advisory councils. And it's kind of a partnership between the facilities within a certain region of State. And there's seven regions we've broken it down into. The hospital association within a region; facilities within a region; and the Department of Health people to really take a look at the data system from a standpoint of areas of common interest. Does this region of ours stand out from anybody else? How do we compare to others? Is there something we'd like to study and then feedback to the rest of the State? And that review is very positive.
Frankly, though, there's also those that aren't really playing fully by the rules. And that was the basis for the commissioner's letter that I mentioned earlier. And that really is—you know, that becomes part of our surveillance activity. Not part of the collaborative, but more the punitive side of things because it's really not fair to those who play by the rules and report openly and share information and try and use it positively to be undermined those who—by those who do not.
RIDLEY: One thing I want to add, too. This is Nancy again.
In Massachusetts, our system is not confidential. The materials and information, with the exception of patient name and some peer review materials, everything is open and available for the public. So we're in a little bit of a different position where there can be more repercussions for what is filed from a public media stand.
UNIDENTIFIED PARTICIPANT: And do you have punitive damages—punitive punishment if they don't report?
RIDLEY: Well, actually, the only thing right now—it's more the issue of they get cited for deficiency—a State deficiency. This is not a Federal requirement to report, just a State requirement. So it's more the mortification of not—of getting cited with a deficiency. Technically, if you had enough deficiencies, you could de-license the hospital, but that's not about to happen. So—
O' SHULSKY: Yeah. I—this is Janet.
I wanted to add that I think this is where, you know, sort of seeing a purchaser can help the equation, too. I mean, I think purchasers have a nice role in sort of promoting that behavior change because we can put money with it, and we can put public recognition with it, and we can actually put volume business with it. And, so, I think that helps to reinforce what Nancy and Fred have been talking about. And once you identify those practices, then you evaluate the things that work and don't work. The purchaser can one, you know, has leverage to bring people to the table but then also has leverage to reward good performance. And I think that can be an important piece in helping that behavior change happen.
ADAMS: Thank you.
UNIDENTIFIED PARTICIPANT: We have a call though that I think that—an E-mail that deals with some of this because the fear factor here as we can hear from these calls is fairly high. This comes from Karen from the Ohio Department of Health Services. Physicians and nurses have an ethical obligation to report errors to the patient and family as soon as possible. Yet reporting must be confidential due to fear of malpractice claims. How do you propose to protect patient rights if reporting can't be used when serious damages are done to people's lives?
UNIDENTIFIED PARTICIPANT: Well, from the-this Fred. And I answer that from New York. Actually one of the patient's rights sections in our regulations effectively requires that if a patient is a subject of an adverse event or error that they are informed of that by the facility or practitioner involved. That doesn't necessarily mean it's public. But that doesn't prevent it from becoming public from that point of view either and that does happen. I mean do—patients do—you know we actually we've found though that if you are open with patients and tell them and deal with the situation and rectify it up front, that you're far better off than not having to find out from a different -
UNIDENTIFIED PARTICIPANT: I agree 100 percent. In Massachusetts, the requirement to report—I mean it's the—we take in—we probably—we get about 1,000 events a year, serious incidents. We have 107 licensed hospitals. We're a lot smaller than New York. But we get about 1,000 serious incidents a year. And about half of them actually come in from consumers. So about—it's about 50/50. So consumers report incidents as well as—do they always result in deficiencies? No, they don't. The serious incidents that come in from facilities-we have to remember we're looking at systems problems as opposed to individual practitioner issues as well. And if we do see an issue that could more be a practitioner issue, we'll send it to our Boards of Registration. However, we're really focusing—and we believe that's where the focus should be—are on the systems issues that aren't involved...
HIEGEL: And this is Fred again. I couldn't agree with Nancy more, particularly from the standpoint, as an example, years ago a medication error occurs and that has an adverse impact on a patient. What's the first thing that happens? Fire the nurse. What we're really trying to get at now from the quality improvement point of view and certainly the use of the root cause analysis format is to look at the system. And what happened in that system that allowed this individual event to take place? I mean, yeah, there was perhaps some human error but something had to set the stage or wasn't enough fail safe built into the system to prevent it from occurring in the first place.
UNIDENTIFIED PARTICIPANT: We have seen many situations, many serious incidents that occurred where the licensed professional was as much a victim of a systemic flaw as was the patient. And it's really a tragedy. And it's not just a tragedy for the patient and the family but also for the professionals involved.
UNIDENTIFIED PARTICIPANT: There is a real incentive to report just based on that that ultimately it will involve improvement of the system and will make their jobs easier and help everyone, not just the patients.
UNIDENTIFIED PARTICIPANT: Exactly.
HIEGEL (?): And that's really the overall intent. I agree.
DIBIASI (?): Richard from the Wisconsin Department of Health. Are you back on? Evidently you got cut off.
GARY ONEN, WISCONSIN DEPARTMENT OF HEALTH: Hi. This is Gary Onen calling in again from Wisconsin.
UNIDENTIFIED PARTICIPANT: Hi Gary. Well, they keep telling me it's Richard so I'm sorry.
ONEN: Dr. Carr is here and he's the one who did dial in and register.
DIBIASI (?): OK.
ONEN: I had a question for the panel. It's concerning the Grassley/Lieberman SAFE Act, which is going to apparently be thoroughly prescriptive in defining adverse events, medication errors, and other things that have to be reported at the Federal level for Medicare and Medicaid to the Department of Health and Human Services. And I'm wondering are you—are your States going to accept that reporting as equivalent? Or are you going to require separate reporting for your State programs?
HIEGEL (?): Well, I can answer first from New York. And what we've tried to do frankly is not have duplicate or redundant or different systems and in fact we've worked quite closely with the Joint Commission. If you'd look at our definitions of reportable events and various categories, the timeframes that we use in our system. The Joint Commission actually adopted and modeled after much of that given our experience. You know our real goal is not to have duplicative systems for our hospitals in New York State. And we are trying to—that's really one of the reasons we're trying to openly share what we've got now and have others adopt it as compared to having something else imposed upon us.
RIDLEY (?): Well, I'm—being from Massachusetts, we're—we've always been adamantly opposed to any preemptive legislative Federal systems. I think the dilemma would be we do have mandatory reporting in our State. I think Grassley and the SAFE Act allow you to report to one of three entities. And that if you report to any one of them then it's—you're OK. You're covered. I think that would go down pretty hard in Massachusetts. Unless the Federal Act was preemptive on State, which I doubt that it would be. Then I think in those States that have mandatory reporting, unless we changed our laws, our ceiling would be—our ceiling would be higher than what is required in the Federal Act.
DIBIASI (?): Let me ask each of you this question. Do you think States are going to be taking the IOM report seriously? And if so, what do you think will happen if—and if not, what do you think will happen if they don't act?
HIEGEL (?): Well, maybe I'll start out. You know I think they will because my understanding is—and I mentioned earlier the steering committee we have. We have a consumer representative on that steering committee. Well, he also sits on the IOM panel that developed this report. And he is very committed to both the prevention and reduction of errors as well as public sharing of information. And he's described it as an initial report with other reports that are planned to really keep this as a national focus and they're really trying to model after, to some extent at least, the airlines industry, you know, and the safety that's built into that system.
UNIDENTIFIED PARTICIPANT: Which we are thinking about, by the way, our next call.
HIEGEL (?): But, yeah, clearly that—the impression I get is that the Institute of Medicine is going to stay with this until everybody gets the message and antes up.
UNIDENTIFIED PARTICIPANT: And I think States will take a serious—I think States have taken it seriously. I think we've seen a lot more interest on the part of State since the release of the Institute of Medicine report. I think they'll each handle it differently depending on their situation. I mean that's one of the characteristics of States. We each approach similar problems in different ways depending on our particular population, politic circumstances, et cetera. I think that one fear States have is that in some ways owning the problem and beginning to do something about it requires you to admit that perhaps you weren't doing as much as you could before. And I think that's a hurdle that States have to get over because in reality I think for the most part consumers have thought that the healthcare system is perfectly safe and we're not suggesting that it's terribly unsafe. It's still a good healthcare system. But there is a lot of—there are a lot of opportunities for improvement out there. And for us to openly discuss and say, "We've got to fix it," is to be able to hear consumers say, "But I thought you were taking care of this already."
RIDLEY (?): I think there's been so much media and public attention and awareness in Massachusetts that we've already admitted that there was more that both we in government as well as the professional organizations can and should do in terms of developing the prevention agenda. And I think that there are—there are some States where it just was not on the radar screen I think until the IOM report came out last year. I think that there—the IOM report, even for States like Massachusetts or New York, did help to focus on perhaps some new opportunities to look at the Federal ASRS (Aviation Safety Reporting System) aviation type reporting system to perhaps even get—gain more knowledge from some of the events that don't actually result in serious outcomes that perhaps those that could have if they had not been caught. And I think it's given us some new ideas about how to gain intelligence and information from those types of events.
DIBIASI (?): What do you think States can do to—if there's one thing and I don't—I don't know it may vary State by State but if there's one thing States could do that would really give them a lot of bang for the buck when it came to this, what would you suggest based on your experience?
UNIDENTIFIED PARTICIPANT: I'd strongly endorse the coalition concept to get the regulatory—both the regulatory and the quasi regulatory Dean status type organizations, Federal and State together in the same room with professional organizations, the purchasers, and consumers.
UNIDENTIFIED PARTICIPANT: If they have the cash flow.
UNIDENTIFIED PARTICIPANT: Get them—
UNIDENTIFIED PARTICIPANT: But maybe you could—maybe, because of your—
UNIDENTIFIED PARTICIPANT: It's well worth it. It's well worth it, well worth it. And I think it would be well worth it in any State.
DIBIASI (?): Was there any shortcut now that you've—it took you 18 months to get through all that was there anything in hindsight you think you could have done to have sped that process up a bit?
UNIDENTIFIED PARTICIPANT: I think we're in a different environment now that IOM's report has come out. I think because there have—there has been some breaking of the way by having some of these coalitions formed. There was one in Pennsylvania as well that was formed on a smaller scale. I think that it takes—you do have to develop—you have to have a willingness. The one thing is that—and other States that I've talked to, sometimes if you have some parties that are just afraid to open up and share. And I can't, you know, if you have a party like a regulatory agency that has a very narrow in the box type vision, you have to find individuals and entities that are willing to think outside of the traditional box. And usually you can do it at some level. Go to the top—it's sort of like what we say about the institutions themselves, you need the commitment at the leadership level. You have to go to your highest levels. Don't—you don't necessarily go to your mid—level bureaucrats. Go to the heads of the agencies. Because I think you'll see the broadest vision at the leadership level within the State agencies as well.
DIBIASI (?): And you certainly had incentive in Massachusetts because of your situation the public attention it garnered. But you know last week we heard that when the IOM report came out, more than half of all media outlets reported on it. And if IOM continues to keep this as a front burner issue, it's certainly going to get national attention. So it won't be that it's just one State feeling as though they're culpable.
UNIDENTIFIED PARTICIPANT: I think too if you look for your clinicians, look—like we're lucky we have the Lucien league, the Harvard School of Public Health. We have Don Berwick and IHI (Institute for Healthcare Improvement). We have a lot of public health academia that are invested in this issue and have been a part of—I think in any State you can look to some of your medical schools, your public health institutions, you'll find individuals and entities who have looked at it and are doing work in this area.
O' SHULSKY (?): I would say—I would certainly echo what Nancy says in terms of coalition. I think I sort of—I think one step back though. It's important for States to fundamentally deal with the issue of the fear and the notion that we've been in kind of a punish the individual situation and really bring the dialog to form, really try and move people off of that. And help them understand that these are really systems issues that as the IOM report title aptly says, "To Err is Human." And what we're really looking at trying to do is put systems in place that help the professionals, the individual practitioners work as fast as they possibly can into put in system redundancies so that errors don't happen. And I think trying to sort of move everything off that punishment and more to a quality improvement cycle, very important for States—for States because we are the regulators. We license health professionals. We give them their credentials. We take them away. And it's important for States to sort of lead that effort.
UNIDENTIFIED PARTICIPANT (?): And if the States don't ask, well professionals ought to ask.
RIDLEY (?): Well, I think—I think they—the Federal Government's giving the States the opportunity to step up to the plate and be the ones to act. And I think that's appropriate and it's right. I think one other point that I can really emphasize is you need to try to focus on, pick out the two or three premier health media people in your market area. And in our case it's entities like the Boston Globe and some of our TV media. And pick out the two or three really key media representatives and educate them. Bring them in on the process. Have them get the same religion that we're getting in terms of collaboration, cooperation, and prevention. And that's been critical to our success. We've had excellent editorials in the Boston Globe. We've had excellent media stories covering the coalition and I think that if you can—if you can really—if you can educate the media, you go a big distance towards achieving your goal.
HIEGEL (?): And I agree and based on, you know, building on what you said, you know I really think that all stakeholders including consumers have to have a role in the collaboration. And you really have to work together to develop a workable system towards a common goal and you need buy in from everybody that participates. And that's how we got the buy in, by having you know all these various entities around the table and participating in the development of this system and it really is a common goal. You know when you sit down and you talk about it, everybody wants to have the best quality in the facilities within the State and obviously recognizes that there's always room for improvement. And with the common goal of quality improvement, you really get a common, you know, common mission and if you get buy in of all the participants I think you have a much better chance of having it happen properly.
DIBIASI (?): In the time that you've—your coalitions and systems have grown and matured, have you seen a difference in the types of reporting you were getting earlier on and the types that you're getting now?
HIEGEL (?): We certainly, absolutely have in New York, a substantial and dramatic increase. And at one time—you know one of the things that we tried to do and I stressed this earlier was that a clear and understandable definition of what's reportable. If there's any flaws in the system, any gray in the system, I can tell you that will bring about incomplete and inconsistent reporting. So you've got to work very hard on the system that way and we've done that and I think through the collaborative effort we've gotten a lot more buy in. I think by having the database available to facilities to actually use it for their quality improvement, we're giving something back. If they're historically just a one way reporting sort of thing and I really think through that, you know, we've seen a dramatic increase in reporting, yes.
RIDLEY (?): I'd second that. We don't have the computerized database at this point. Any of the reports, however, are available and actually they have been extensive. The Boston Globe did a major series, week long series, on—based on our report that was actually excellent. It was an excellent series. So any of the reports that we have are individually available. Our goal and our hope is to go towards the type of system that Fred has and with the new legislation that's been filed in Massachusetts as well, which some of you have seen, there would be the Betsy Leeman Center for patient safety named after the Boston Globe columnist. And all of the existing information and data aggregated would go into the center and become proactively available in addition to having new data sets for the near miss or near hit or however you want to call it, information.
UNIDENTIFIED PARTICIPANT: I would just add that given next week you're going to be talking about the aviation industry and some of the lessons from there, that's certainly what Fred and Nancy have talked about is certainly the lesson that was seen in the aviation industry too is reporting systems mature and people get to see that the information is used to the way it was intended and that they can use the information and that they see it makes a positive impact on their life. So for example, if something happens in hospital A in New York and that incident report results in hospital B being able to prevent something from happening, those folks see it as improving—helping them improve care. And then they're more likely to report something that they see happening so that it can help someone else as well. So I think it's a—you'll hear a little bit more about that as we talk about the aviation industry. But I expect that system to improve..
DIBIASI (?): And what is the State of the Union, so to speak, in terms of we're talking only about a handful of States that really have systems in place now and even those systems vary.
HIEGEL (?): Yes.
UNIDENTIFIED PARTICIPANT: Yes.
HIEGEL (?): They vary substantially and from, you know, the level that we're talking about and recognizing that we've got more room for development and improvement too to States that have virtually nothing in place right now. But I think the catalyst is there. The time is right that some point in the not too distant future, they're going to need to have something and if they don't do it on their own, it's going to be dictated by someone else.
O' SHULSKY (?): Well I think that, as Nancy has said, the Federal Government is giving the States the opportunity to step up to the plate. There's a handful of States that have different models out there. The rest of us who are—may not be doing anything right now certainly can look at those, modify them as appropriate for our States, and start moving but if we don't, the Federal Government appears ready to act.
UNIDENTIFIED PARTICIPANT: And I can just tell you—you know I've mentioned the medication—best practices. But we simultaneously now have work groups that are multi-disciplinary, that are working on prevention of restraint related injuries and death in every setting, not just in hospitals, Long-Term care and psychiatric facilities. We actually have three pods working simultaneously developing best practices. We have a consensus group on wrong side surgery. And we also have one that just started on transfusion related adverse events where we've called 2 years worth of transfusion related incidents, adverse events, and some of them quite serious and are developing some best practices for some of the events that were totally preventable.
DIBIASI (?): I think let's just go around as sort of the final thought section. Any final thoughts to leave the audience with as we move from call 2 to call 3?
HIEGEL (?): No, I think probably the one salient point is that—you know really everybody has a common goal here. And it really is for improving safety in the healthcare system. I agree wholeheartedly what was said earlier that the public really expects that it's there now. We know that it could be improved. As that information becomes more and more available to the public, I think there's going to be a lot more public pressure and demand for that. And I do honestly believe that whether you're a regulator, a consumer, or a provider that you're intent is to provide the best quality of care that can be to patients and we should proceed with that in mind.
UNIDENTIFIED PARTICIPANT: And you don't want to get to the point where the public has lost faith in the safety of the healthcare system...
HIEGEL (?): Absolutely.
UNIDENTIFIED PARTICIPANT: Before you start trying to rectify.
UNIDENTIFIED PARTICIPANT: Well, I'm going to take sort of the business purchaser perspective. I think there's a real business cases of purchaser of healthcare too and there's not—I certainly don't disagree with anything Fred has indicated but just sort of in addition to that, we know that medical errors contributed significant amounts of the total healthcare bill in this county, something on the order of $29 billion a year spent on additional healthcare costs related to correcting the errors or some otherwise treating conditions that developed as a result of the errors. And that's only half the tab. There is also lost productivity and lost income to people. So it's a huge economic cost for us. And I think given—and we're entering a time again where we're having medical inflation. We have cost pressures on the healthcare system. We know how to fix some of these things. To not do so is really a terrible thing and we're losing people. People die as a result of this and we need to remember that.
RIDLEY (?): I think that States are on the front lines. We are the front line. We have an opportunity to step forward and take responsibility for preventing medical errors. I think we have a unique opportunity to partner with the Federal agencies, national organizations, as well as our own State organizations in coming up with solutions that are system safe and to change the emphasis from one of individual blame to creating a system safe approach to patient safety. And I think that States need to step up to the plate and not hang back and wait for someone else or the Federal Government to come up with the answers.
DIBIASI (?): Nancy Ridley, Janet O 'Shulsky, and Fred Hiegel, thank you all for joining us this afternoon. And if we didn't get to your question today, you can E-mail them to us at info@ahrq.gov and depending on the number of questions, we will try to answer you directly. Again, we'd appreciate any feedback you may have about this, our teleconference series, by E-mailing comments to info@ahrq.gov.
We also encourage you to send us any research questions you're facing at the State or local levels for AHRQ's consideration as we plan the Agency's research priorities. I mentioned at the beginning of the show that we'll have copies of the audio teleconference available for purchase several weeks after the series is completed. The cost for this series will be $10 or for $25 you can order a complete tape set of all sessions recorded at the March 2000 workshop. To get information about ordering, you can go to the AHRQ Web site and once again, that's www.ahrq.gov, then select State and Local Policymakers, or you can call the AHRQ Publications Clearinghouse at 1-800-358-9295 and ask for audio tapes AHRQ-00AV11 for the workshop tapes and AHRQ-00AV11A for the audio conference tapes. Those are entitled, "How Safe is Our Healthcare System? What States Can Do to Improve Patient Safety and Reduce Medical Errors."
Also, we'll send you posting on the AHRQ Web site, a summary of the March 2000 ULP workshop about medical errors. We hope you'll join us for the final teleconference in this series. That's next Monday. I should say the Monday after June 5th from 2:00 until 3:30 p.m. Eastern Daylight Savings time, when the topic will be, "A System's Approach To Improving Safety Translating Lessons from the Aviation Industry".
And this session was rated as one of the best at ULP's March workshop. We talked—mentioned it a little bit today. In this session we'll be talking about a conceptual framework and systems approach for addressing issues of patient safety. We'll also hear from Dr. John Eisenberg, the Director of AHRQ, who will tell us what initiatives the Federal Government is proposing and also Trish Reilly, Executive Director of the National Academy of State Health Policy, and a member of the IOM panel will be here to help wrap things up.
We hope you can join us for this final call in the series. If you haven't already registered, please call 1-888-739-2195. We look forward to having you join us and thanks for joining us today. Bye.
Internet Citation:
How States Can Improve Patient Safety and Reduce Medical Errors. Transcript of part two of the series of National Audio Teleconferences sponsored by the User Liaison Program, Agency for Healthcare Research and Quality, conducted on May 24, 2000. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ulp/trulp524.htm
Return to Teleconferences: How Safe Is Our Health Care System?